Airline Transport Pilot FAA Senior Aviation Medical Examiner 

Aeromedical Forum



November 1, 2020

Headaches and aviation are frequent companions. Anyone who has made a long cross country flight knows why. Hours of engine noise and vibration, traffic, buildups, headwinds that make your fuel consumption jump…any and all are headache generators. That’s just part of flying. So why would the FAA care about something that’s pretty much built in to aeronautical endeavors? Well, there are headaches and there are headaches. What I’ve been talking about is what are referred to as tension headaches, that achy feeling in your temples, sometimes the feeling of a band encircling your head. They are caused by contraction of the muscles surrounding your skull, a head cramp if you will. Any on-going stress, physical or mental can cause them as can lack of sleep, hunger, excessive heat or cold. They are common and usually mild. A little aspirin, ibuprophen or Tylenol usually takes care of it, as does removal of the causative agent. Sometimes however a tension headache can be incapacitating. In other instances it falls between the extremes of “no-big-deal” and “I’ve-gotta-lay down.” That is where the danger zone lies. If you are zonked out, you know it and hopefully have the common sense not to get into a cockpit. A moderate headache however may still impair your ability to plan, observe and react to in-flight threats. If you are like many pilots, you have a strong sense of denial as to anything being wrong. You believe that your piloting skills are not going to be diminished by a little headache; besides “I gotta get there!” If it’s in the grey zone, give yourself the benefit of the doubt. Take a mild analgesic and sit or lie down in the pilots lounge for a while. Then see how you feel before you try to fly into Chicago Bravo and land at Midway.

Of course there are other types of headaches and one severe type, migraine is of great concern to the FAA. They are not uncommon. About 16% of the population will experience one at some time or another. They are most common between the ages of 18 and 44. They typically are very severe. People describe it as “like having a hatchet buried in your brain.” It can be preceded by a visual prodrome—blurring, flashes of light, jagged patterns. Often folks experience a severe sensitivity to sound and/or light. They just want to lie in a quiet, dark room. Needless to say they can be incompatible with flight. So if you have them, the FAA wants to be sure that they are controlled and are not likely to occur while you’re flying. In many instances, your AME will be able to issue a medical certificate if you meet criteria spelled out in the “Migraine and Chronic Headache Worksheet” under the CACI (Conditions an AME Can Issue) Program. Specifically, your treating physician must state that your condition is stable and headaches are well-controlled. You can’t have a Variant Migraine with a symptom pattern different from what I’ve described. For example an Ocular Migraine where vision is impaired definitely falls out of the category of a Typical Migraine. Other variants can mimic stroke, cause fainting or dizziness. They also are disqualifying and must be further evaluated by the FAA. You should not be having more than one migraine per month. Your symptoms should be controlled with one of the medications specified by the FAA not including injections or narcotics. If you have to use one of these approved prescription medications you’ll have to ground yourself for 24 to 96 hours. Also you should not require more than two urgent care visits and no hospitalizations for migraine over the past year. If you don’t fulfill the CACI criteria, you will have to have your case deferred to the FAA for further evaluation. Fortunately there are several medications that are very good at preventing migraines and are acceptable for flight status. Check with your AME or the FAA website

Ultimately whether or not you fly with a headache is a matter of pilot judgement. Be sure your headache is not a type that’s disqualifying. Be conservative. Be easy on yourself!

Fly wisely. See you next month.


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